RAY PEARSON
CHIEF BUILDING OFFICIAL
AMUSEMENT REDEMPTION MACHINE
GAME ROOM LICENSE APPLICATION
Name: Phone No.:
Driver’s License No.:
Home Address:
Street City State Zip Code
If more than one person owns 25 percent or more interest in the game room location – applicant must
provide the name, address, telephone number, and driver’s license number for all persons by attaching
said information to this application.
Applicant must provide the name, address, telephone number and driver’s license number of all Corporate
Officers, if any, of such business by attaching said information to this application.
Business Name:
Address:
Business Location Street City State Zip Code
Business Phone No.:
Emergency Contact Information
Name: Phone No.:
Address:
Street City State Zip Code
Is the Business Incorporated? Y / N
If Incorporated, provide the name of the business registered with the Texas Secretary of State:
Is the Business a Partnership? Y / N
If a partnership, provide the name, address, telephone number and driver’s license number of each of the
general and limited partners by attaching said information to this application.
Are you the owner of the premises where the business is located? Y / N
If you are not the owner of the premises, please furnish the name, address, and telephone number of the
property owner:
114 WEST HIGGINS ● HUMBLE, TEXAS ● 77338 ● (281) 446-6228
AMUSEMENT REDEMPTION MACHINE GAME ROOM LICENSE APPLICATION 08/2021
Property Owner Name:
Address:
Street City State Zip Code
Telephone No.:
Are you / Will you be the operator of the premises to be permitted? Y / N
If you are not the operator of the premises, please furnish the name, address, and telephone number of the
operator:
Operator Name:
Address:
Street City State Zip Code
Telephone No.:
Number of Amusement Redemption Machines to be Permitted:
Serial Number of Each Amusement Redemption Machine:
Has the previous license of the applicant, or if applicable, a corporate officer of the applicant, been
revoked within the last two years? Y / N
List the previous occupation(s) of the applicant and, if applicable, all corporate officers and partners
of the applicant within the preceding five years (attach additional information to the application if
necessary):
AMUSEMENT REDEMPTION MACHINE GAME ROOM LICENSE APPLICATION 08/2021
Applicant must provide a copy of valid game room permit issued by Harris County
Please attach copy of permit to the application
Applicant must provide a floor plan of the amusement redemption machine game room
The floor plan should include a layout of the interior of the premises specifically including, but not limited
to, the location of all amusement redemption machines, coin-operated machines or devices, the manager’s
station(s), restroom facilities, kitchen and bar facilities, if any, and all areas to which patrons will not be
permitted.
Applicant must provide a notarized statement, under oath, that:
Please attach statement to the application
1) All the facts contained in this application are true and correct;
2) The amusement redemption machines are not and will not be used as gambling devices;
3) The location and operation of the amusement redemption machine game room will not violate any
applicable deed restrictions;
4) The amusement redemption machine game room will be operated in accordance with all laws.
Applicant certifies that the occupation tax has been paid for each amusement redemption machine
within the premises and is responsible for paying the game room license and inspection fee of $300.00
payable to the City of Humble, Texas.
Amusement Redemption Machine License is valid from January 1
st
through December 31
st
and must
be renewed annually. Applicant may file the renewal application and associated fees for the
following calendar year beginning on October 1
st
.
Please note, this application is for the licensing of a premise to operate Amusement Redemption
Machines. The applicant/business/owner/operator is still responsible for the filing of the Application
for Coin Operated Game Machine Permit for each machine located within their premises.
Applicant Signature Date
Application Date: Reviewed By:
Application Approved / Denied:
License Number: Tax Number: Expiration:
AMUSEMENT REDEMPTION MACHINE GAME ROOM LICENSE APPLICATION 08/2021
CITY OF HUMBLE
ANNUAL APPLICATION FOR AMUSEMENT REDEMPTION
MACHINE
BUSINESS NAME, MAILING ADDRESS AND TELEPHONE NO.:
NOTE: APPLICATION TO BE COMPLETED BY BUSINESS OWNER OR MANAGEMENT WHERE MACHINES
ARE PLACED. LIST ALL MACHINES WITHIN BUSINESS INVENTORY
MACHINE MODEL
MACHINE SERIAL NO.
YEAR & STATE OF TEXAS
COMPTROLLER
PERMIT NO.
CITY OF HUMBLE TAX NO.
ASSIGNED.
AMUSEMENT REDEMPTION MACHINE GAME ROOM LICENSE APPLICATION 08/2021
